Download Risk of Anaphylaxis After Vaccination of Children and Adolescents

Risk of Anaphylaxis After Vaccination of Children and Adolescents
Kari Bohlke, ScD*; Robert L. Davis, MD*‡; S. M. Marcy, MD§; M. M. Braun, MD储;
Frank DeStefano, MD¶; Steven B. Black, MD#; John P. Mullooly, PhD**; and Robert S. Thompson, MD‡‡
for the Vaccine Safety Datalink Team
ABSTRACT. Objective. To quantify the risk of anaphylaxis after vaccination of children and adolescents.
Methods. The study population consisted of children
and adolescents who were enrolled at 4 health maintenance organizations that participated in the Vaccine
Safety Datalink Project. For the period 1991–1997, we
identified potential cases by searching for occurrences of
International Classification of Diseases, Ninth Revision
(ICD-9) code 995.0 (anaphylactic shock), E948.0 through
E948.9 (adverse reaction from bacterial vaccines), and
E949.0 through E949.9 (adverse reaction from other vaccines and biological substances). At 1 study site, we also
included a range of other allergy codes. We restricted to
diagnoses on days 0 to 2 after vaccination (ICD-9 995.0) or
day 0 (all other ICD-9 codes). We then reviewed the
medical record to confirm the diagnosis.
Results. We identified 5 cases of potentially vaccineassociated anaphylaxis after administration of 7 644 049
vaccine doses, for a risk of 0.65 cases/million doses (95%
confidence interval: 0.21–1.53). None of the episodes resulted in death. Vaccines that were administered before
the anaphylactic episodes were generally given in combination and included measles-mumps-rubella, hepatitis
B, diphtheria-tetanus, diphtheria-tetanus-pertussis, Haemophilus influenzae type b, and oral polio vaccine. One
case of anaphylaxis followed measles-mumps-rubella
vaccine alone. At the site at which we reviewed additional allergy codes, we identified 1 case after 653 990
vaccine doses, for a risk of 1.53 cases/million doses (95%
confidence interval: 0.04 – 8.52).
Conclusions. Patients and health care providers can
be reassured that vaccine-associated anaphylaxis is a rare
event. Nevertheless, providers should be prepared to
provide immediate medical treatment should it occur.
Pediatrics 2003;112:815– 820; anaphylaxis, vaccination,
vaccine adverse reactions.
From the *Center for Health Studies, Group Health Cooperative, Seattle,
Washington; ‡Departments of Pediatrics and Epidemiology, University of
Washington Schools of Medicine and Public Health, Seattle, Washington;
§Kaiser Foundation Hospital, Panorama City, California; 储Division of Epidemiology, Office of Biostatistics and Epidemiology, Center for Biologics
Evaluation and Research, Food and Drug Administration, Rockville, Maryland; ¶National Immunization Program, Centers for Disease Control and
Prevention, Atlanta, Georgia; #Pediatric Vaccine Study Center, Northern
California Kaiser Permanente, Oakland, California; **Center for Health
Research, Northwest Kaiser Permanente, Portland, Oregon; and ‡‡Department of Preventive Care, Group Health Cooperative, Seattle, Washington.
Received for publication Mar 28, 2003; accepted Jun 10, 2003.
The findings and conclusions of this study do not necessarily represent the
views or policies of the Department of Health and Human Services or the
American Association of Health Plans.
Reprint requests to (K.B.) Center for Health Studies, Group Health Cooperative, 1730 Minor Ave, Ste 1600, Seattle, WA 98101-1448. E-mail:
[email protected]
PEDIATRICS (ISSN 0031 4005). Copyright © 2003 by the American Academy of Pediatrics.
ABBREVIATIONS. MMR, measles-mumps-rubella; HMO, health
maintenance organization; VSD, Vaccine Safety Datalink; ICD-9,
International Classification of Diseases, Ninth Revision; CI, confidence
interval; DT, pediatric diphtheria-tetanus; DTP, diphtheria-tetanus-whole cell pertussis; Hib, Haemophilus influenzae type b; OPV,
oral polio vaccine; VAERS, Vaccine Adverse Event Reporting
System.
A
naphylaxis is a potentially fatal hypersensitivity reaction resulting in cutaneous, respiratory, cardiovascular, and/or gastrointestinal signs and symptoms. Common causes of
anaphylaxis in children include peanuts and other
foods, medications, and hymenoptera stings. Vaccine-associated anaphylaxis has been reported, and
the Institute of Medicine accepts a causal relation
with the combined measles-mumps-rubella vaccine
(MMR), hepatitis B vaccine, and diphtheria and tetanus toxoids,1 but the number of vaccine-associated
cases seems to be small. Because the risk of vaccineassociated anaphylaxis is not well quantified, we
describe the incidence of anaphylaxis after vaccination among children and adolescents at 4 West Coast
health maintenance organizations (HMOs) participating in the Centers for Disease Control and Prevention’s Vaccine Safety Datalink (VSD) project.
METHODS
Study Sites
The 4 HMOs participating in the study were Group Health
Cooperative, Seattle, Washington; Northern California Kaiser Permanente, Oakland, California; Northwest Kaiser Permanente,
Portland, Oregon; and Southern California Kaiser Permanente,
Los Angeles, California. These sites are participants in the VSD
project, which since 1991 has been funded by the Centers for
Disease Control and Prevention to study adverse events after
vaccination.
Study Population and Time Frame
The study cohort consisted of children and adolescents aged 0
through 17 years at 3 sites and aged 0 through 6 years at 1 site. A
total of 2 226 907 children and adolescents in this cohort were
enrolled in their respective HMO for at least 1 day between 1991
(for 3 of the sites) or 1992 (for 1 site) and the end of 1997.
Assessment of Exposure
Vaccines that were administered during the study period were
identified from the automated immunization data collected by
each study site. These data include type of vaccine and date of
administration. The quality of these data has been assessed in a
previous study, which noted high concordance between the automated data and data abstracted from the medical record.2 These
data provided the denominator for calculations of risk of anaphylaxis after vaccination, and linkage with the outcome data allowed
PEDIATRICS Vol. 112 No. 4 October 2003
815
for identification of allergic reactions occurring the same day as
vaccination.
Identification of Potential Cases of Vaccine-Associated
Anaphylaxis
We searched the automated encounter databases at each site for
occurrences of International Classification of Diseases, Ninth Revision
(ICD-9) codes suggestive of anaphylaxis. These databases included hospitalizations and emergency department visits at all
study sites. Availability of outpatient clinic data differed across
study sites: 1 site had outpatient clinic data for the entire study
period, 1 site had data from 1995 onward, 1 site had data for 1997
only, and 1 site did not contribute outpatient clinic data. Given
this variability in outpatient data, we conducted 2 sets of analyses:
1 including all study sites and 1 restricted to the site with complete
outpatient data. The site with complete outpatient data had data
for children 0 through 17 years of age.
We searched for diagnoses of ICD-9 code 995.0 (anaphylactic
shock), E948.0 through E948.9 (adverse reaction from bacterial
vaccines), and E949.0 through E949.9 (adverse reaction from other
vaccines and biological substances). We restricted our review to
diagnoses occurring on days 0 to 2 after vaccination (day 0 defined
as the same day as vaccination) for ICD-9 code 995.0 and day 0 for
ICD-9 codes E948.0 to E948.9 and E949.0 to E949.9. Because some
cases of anaphylaxis may receive other related allergy diagnoses,
at 1 of the study sites, we also performed a chart review of all day
0 diagnoses of 708.0 (allergic urticaria), 708.9 (urticaria unspecified), 995.1 (angioneurotic edema), 995.3 (allergy unspecified),
695.1 (erythema multiforme), and 995.2 (unspecified adverse effect
of drug, medicinal and biological substance).
Definition of Anaphylaxis
To classify episodes as “probable” or “possible” anaphylaxis,
we considered the number and type of organ systems involved,
the rapidity with which signs and symptoms appeared after exposure to a precipitating agent, and treatment (Fig 1). The decision
to incorporate treatment was based on our knowledge that
prompt treatment of an anaphylactic episode can stop progression
to ⬎1 organ system. Cases defined as “probable” anaphylaxis
required manifestations involving ⬎1 organ system (cutaneous,
respiratory, cardiovascular, and/or gastrointestinal), occurring
within 4 hours of exposure to a precipitating agent, with subsequent treatment. “Possible” anaphylaxis included 3 groups: 1)
those with involvement of ⬎1 organ system (described above),
with signs and symptoms developing within 4 hours of exposure,
and untreated; 2) those with involvement of ⬎1 organ system,
occurring ⬎4 hours (or an indeterminate time period) after exposure, who were treated; and 3) those with involvement of only 1
organ system, with symptoms developing within 4 hours of exposure, who were treated.
Chart Abstraction
For each potential case, we reviewed the medical record to
collect information about date of onset, signs and symptoms,
cause posited by the treating physician, time interval between
exposure and onset of signs and symptoms, treatment, and history
of atopy. Information was also recorded on specific manifestations
within 4 categories of signs and symptoms integral to diagnosing
anaphylaxis: mucocutaneous, respiratory, cardiovascular, and
gastrointestinal. Time interval from posited exposure to onset of
Fig 1. Algorithm for assessing anaphylaxis.
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signs and symptoms was categorized as ⬍5 minutes (or “immediate”), 5 to 59 minutes, 1 to 4 hours, ⬎4 hours, and unknown. We
collected information about all treatments administered by medical personnel, including epinephrine, parenterally administered
antihistamines, parenterally administered corticosteroids, intravenous fluids, and bronchodilators. A child was classified as potentially atopic when he or she had a medically recorded history of
asthma, hay fever, eczema, allergic bronchitis, reactive airway
disease or bronchiolitis, other allergies, or use of bronchodilators.
We collected history of these conditions or medications from chart
notes pertaining to the anaphylactic episode or its follow-up (we
reviewed chart notes for the month after the episode). Although
this documentation followed the anaphylactic episode, we included only those conditions or medications that were originally
diagnosed or prescribed before the anaphylactic episode.
Analysis
We calculated the risk of anaphylaxis after vaccination as the
number of identified cases of anaphylaxis per million doses of
vaccine administered. We estimated risk for all vaccines combined, as well as separately by vaccine type. When an accepted
case of anaphylaxis had received ⬎1 vaccine simultaneously, that
case contributed to the risk estimate for each of the vaccines that
he or she had received. We estimated risk for all 4 study sites
combined and also conducted an analysis restricted to the 1 study
site that reviewed a range of other related diagnoses and that had
complete outpatient clinic diagnosis information. We calculated
95% confidence intervals (CIs) for the risk estimates when the risk
was ⬎0. When the risk was 0, we calculated 1-sided 97.5% CIs.
RESULTS
We identified 664 diagnoses of interest and reviewed 657 (Table 1). We were unable to review 7
diagnoses because of missing chart information.
These 7 consisted of 3 diagnoses of 995.3 (allergy
unspecified) and 4 diagnoses of E948.6 (adverse reaction from pertussis vaccine).
We accepted 6 of the 657 reviewed episodes as
probable or possible anaphylaxis. However, 1 of the
6 cases was clearly not vaccine related. The patient’s
visit consisted of evaluation for an episode of idiopathic anaphylaxis that had occurred a few days
before vaccination. At the time of this evaluation, it
was noted that the patient was due for hepatitis B
vaccine and the vaccine was administered. This appeared in the automated data as a day 0 reaction,
although the reaction preceded vaccine administration. The 5 remaining cases are described in Table 2.
Of these 5, 2 are questionable with respect to whether
the reaction was truly anaphylaxis (patient 1: signs
and symptoms not typical of anaphylaxis and not
treated; patient 3: provider doubted whether episode
TABLE 1.
was a true allergic reaction), and 1 was unlikely to
have been caused by vaccination (patient 4: time
interval between vaccination and symptoms was 2
days; cause of the anaphylactic episode was unclear).
None of the anaphylactic episodes resulted in death.
The number of vaccinations administered to the
study cohort was 7 644 049. Given 5 identified cases
of anaphylaxis, our estimate of the risk of anaphylaxis after vaccination is 0.65 cases per million doses
(95% CI: 0.21–1.53). If we exclude the 3 cases that
were questionable with regard to either vaccine association or outcome, then our estimate of the risk is
2 cases per 7 644 049 vaccine doses, or 0.26 cases per
million doses (95% CI: 0.03– 0.95).
One of the cases of anaphylaxis occurred at the
study site for which we reviewed a broader range of
diagnoses and had complete information regarding
outpatient clinic diagnoses. Although we had complete outpatient clinic data at this site, the single case
of anaphylaxis identified was diagnosed in the emergency department. The population of children at this
site had received 653 990 doses of vaccine, for a risk
of 1.53 per million doses (95% CI: 0.04 – 8.52).
The vaccines administered to the patients were
most often given in combination and included MMR,
hepatitis B, pediatric diphtheria-tetanus (DT), combined diphtheria-tetanus-whole cell pertussis (DTP),
Haemophilus influenzae type b (Hib), combined DTPHib, and oral polio vaccine (OPV; Table 2). The 1
subject who received a single vaccine received MMR.
Considering the data from all 4 sites, the risk of
anaphylaxis after these vaccines ranged from 1.1 cases/million doses of hepatitis B to 21.2 cases/million
doses of DT (Table 3). This latter estimate is based on
relatively few doses and a single case of anaphylaxis
and is less precise than the estimates for the other
vaccines (as reflected in the wider CI). We observed
no cases of anaphylaxis after vaccination with combined diphtheria-tetanus-acellular pertussis, influenza, inactivated polio vaccine, adult diphtheria-tetanus, or varicella. For several of these vaccines,
however, our population had received relatively few
doses, resulting in wide CIs.
At the study site with the most comprehensive
data, the 1 case of anaphylaxis had received MMR,
DTP, Hib, and OPV. Although we do not know
which of these vaccines caused the anaphylactic ep-
Number of Diagnoses Reviewed, by ICD-9 Code
ICD-9 Code
No. of Study
Sites That Reviewed
This Code
No. of
Diagnoses
Postvaccine
Days
Reviewed*
995.0 (anaphylactic shock)
E948.0–E948.9 (adverse reaction from
bacterial vaccines) or E949.0–E949.9
(adverse reaction from other vaccines
and biological substances)
708.0 (allergic urticaria)
708.9 (urticaria unspecified)
995.1 (angioneurotic edema)
995.3 (allergy unspecified)
695.1 (erythema multiforme)
995.2 (unspecified adverse effect of drug,
medicinal and biologic substance)
4
4
5
89
0–2
0
1
1
1
1
1
1
2
73
3
457
1
27
0
0
0
0
0
0
* Day 0 is the day the vaccine was administered
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817
TABLE 2.
Description of the 5 Cases of Anaphylaxis With a Possible Vaccine Link
Patient
Age
Diagnosis
Symptoms
Vaccines
1
7 wk
E948.6
DTP-Hib, hepatitis B,
OPV
2h
2
16 mo
E949.9
Petechial lesions,
cyanosis, dyspnea,
tachycardia
Erythema, wheezing,
tachycardia, rash
MMR
Within 1 h
3
17 y
995.0
DT, MMR
Within 1 h
4
10 mo
995.0
DTP-Hib, OPV
hepatitis B
2d
5
19 mo
995.3
MMR, DTP, OPV,
Hib
5–10 min
Facial flushing,
shortness of
breath, nausea,
lightheadedness,
numbness in legs
Swollen lips, rash,
wheezing
Urticaria, pruritis,
swollen lips, slight
stridor
Time Interval
Between
Vaccination and
Symptom Onset
Treatment
Acetaminophen, chest
radiograph,
electrocardiogram
Albuterol,
diphenhydramine
elixir
Epinephrine, IM
diphenhydramine,
IV hydrocortisone,
D5W.
Epinephrine, IM
dexamethasone,
albuterol,
hydroxyzine syrup
Epinephrine, IM
diphenhydramine
History of
Atopy?
No
Yes, asthma
and
eczema
No
Yes, asthma
No
IM indicates intramuscular; IV, intravenous.
TABLE 3.
Observed Risk of Anaphylaxis After Specific Vaccines*
Vaccine
No. of Doses
Administered
No. of Cases of
Anaphylaxis
DT
DTP
DTaP
DTP-Hib
Influenza
Hepatitis A
Hepatitis B
Hib
IPV
MMR
OPV
Td
Varicella
Other
TOTAL
47 171
788 807
448 456
596 645
197 964
23 185
1 852 147
785 010
48 062
848 945
1 546 372
152 636
254 186
54 463
7 644 049
1
1
0
2
0
0
2
1
0
3
3
0
0
0
5
Risk per Million Doses
(95% CI)†
21.2 (0.5–118.1)
1.3 (0.03–7.1)
0 (0–8.2)
3.4 (0.4–12.1)
0 (0–18.6)
0 (0–159.1)
1.1 (0.1–3.9)
1.3 (0.03–7.1)
0 (0–76.7)
3.5 (0.7–10.3)
1.9 (0.4–5.7)
0 (0–24.2)
0 (0–14.5)
0 (0–67.7)
0.65 (0.21–1.53)
DTaP indicates diphtheria-tetanus-acellular pertussis; IPV, inactivated polio vaccine; Td, adult diphtheria-tetanus.
* Includes vaccines administered in combination with other vaccines.
† If risk is 0, the CI is 1-sided 97.5% CI.
isode, we allowed the case to contribute to the vaccine-specific risk estimates for each of the vaccines
received. For the vaccine that caused the episode, the
resulting risk estimate is valid. For the vaccines that
did not cause the reaction, the risk in this population
is 0. The vaccine-specific risks were 8.6 cases/million
doses of DTP (95% CI: 0.2– 47.8), 9.5 cases/million
doses of Hib (95% CI: 0.2–53.0), 9.2 cases/million
doses of OPV (95% CI: 0.2–51.1), and 14.4 cases/
million doses of MMR (95% CI: 0.4 – 80.5).
DISCUSSION
Anaphylaxis can be caused by vaccination and is
among the most serious of vaccine-associated adverse events. However, this study suggests that the
risk of anaphylaxis after vaccination is very low. We
identified 5 cases of potentially vaccine-associated
anaphylaxis in a population of children who had
received roughly 7.5 million doses of vaccine (0.65
cases/million doses). Although this estimate likely
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RISK OF ANAPHYLAXIS AFTER VACCINATION
represents an underestimate of the risk, because at 3
of the study sites we used a restricted set of diagnosis
codes to identify cases and had varying availability
of outpatient clinic data, the risk remained low (1.5
cases/million doses) when we restricted to the study
site at which we considered a broad range of diagnosis codes and for which we had outpatient clinic
data for the entire study period.
Attributing the anaphylactic episodes to a particular vaccine was difficult because the children generally received several vaccines simultaneously.
Only 1 child with anaphylaxis had received a single
vaccine, and this was MMR. The remaining episodes
most often followed diphtheria- and tetanus-containing vaccines (DT, DTP, DTP-HIB), hepatitis B, MMR,
and OPV. These vaccines were also the most frequently administered. Considering data from all 4
study sites, the vaccine-specific risks for these vaccines were generally in the range of 1.1 to 3.5 cases
per million doses. The vaccine-specific risks at the
study site with the most complete data were higher
and ranged from 0 to 14.4 cases/million doses. Because a case contributed to the risk estimates for each
vaccine received, when probably only 1 of the vaccines (or none) caused the anaphylaxis, we likely
overestimated some of the vaccine-specific risks. For
example, the calculation of the risk after MMR at all
4 sites was based on the 3 cases that had received
MMR. Because 2 of these cases also received other
vaccines along with MMR, it is possible that only 1
case was caused by MMR. We observed no cases of
anaphylaxis after diphtheria-tetanus-acellular pertussis, influenza, inactivated polio vaccine, adult
diphtheria-tetanus, hepatitis A, or varicella, but
given the study time frame (1991–1997) and age
range (0 –17 years), our population had received relatively few doses of these vaccines. The wide CIs
reflect the smaller number of doses administered and
should not be interpreted as suggestive of a particularly high or low risk after these vaccines.
Two of the 5 episodes of anaphylaxis occurred in
children with a history of asthma and/or eczema.
Although this proportion is higher than the estimated prevalence of atopy in the general population
of 1 in 6,3 we had too few cases to draw meaningful
conclusions about the prevalence of atopy among
children with vaccine-associated anaphylaxis.
When comparing our results with those of previous studies, it is important to consider the means of
case ascertainment. A strength of the current study is
that it does not rely on passive reporting of anaphylaxis. Although passive reporting systems have
many important uses, including detection of previously unknown adverse events and increases in the
frequency of adverse events, they are prone to underreporting.4 The current study, however, does rely
on the sensitivity of the ICD-9 codes that we reviewed. Previous studies have indicated that anaphylaxis is sometimes coded as a variety of other
allergic conditions.5,6 Some of these diagnoses (eg,
995.3, allergy unspecified) are used frequently, and
review of all of these diagnoses at all 4 sites was not
feasible. The restricted set of codes reviewed at 3 of
the sites, along with the variable availability of outpatient clinic data, may have resulted in incomplete
capture of anaphylaxis at these sites. In addition, 1 of
the sites only had data for children 0 to 6 years of
age. Additional cases of anaphylaxis may have been
identified at this site if data for older children had
been available, but the estimate of the risk would not
necessarily change because the number of vaccine
doses would also increase. To address these limitations, we conducted a secondary set of analyses restricted to the single site at which a broad range of
allergy codes was reviewed and for which we had
complete outpatient data for children 0 to 17 years of
age.
Previous studies of the risk of anaphylaxis after
MMR have generally produced risk estimates at or
below the estimates observed in the present study.
The differences may reflect in part whether the studies used active or passive surveillance systems, because these differ with regard to underreporting. A
Finnish study evaluated serious adverse events after
MMR from 1982 to 1996 in a population that had
received close to 3 million doses of MMR.7 There
were 30 reports of anaphylaxis, 14 of which were
classified as having a possibly causal association
with MMR. All of the anaphylactic episodes resulted
in recovery. On the basis of the 14 cases with a
possible link to MMR, the risk of 5 cases/million
doses is similar to our estimate from all 4 study sites
(3.5 cases/million doses) and not significantly different from the risk estimated from the site with the
most complete data (14.4 cases/million doses, based
on a single case). In the United States, 168 cases of
probable or possible anaphylaxis were reported to
the Vaccine Adverse Event Reporting System
(VAERS) after administration of approximately 94
million doses of MMR, for a reporting rate of 1.8
cases/million doses.8 Finally, in Australia, 1 case of
anaphylaxis was reported during the 1998 measles
control campaign, during which 1.7 million schoolchildren were vaccinated with MMR.9 There were
also 6 reactions defined as anaphylactoid. If all 7 of
these reactions are considered, then the risk is 4
cases/million doses of MMR. There were no deaths
as a result of anaphylaxis.
The risk of anaphylaxis after hepatitis B vaccination was reported in a study of a school-based hepatitis B vaccination program in Canada.10 In 1992,
127 922 doses of hepatitis B vaccine were administered to sixth-grade students. One case of anaphylaxis was reported for a risk of 7.8 cases/million
doses. There were no deaths. The risk estimate in this
study is higher than both the estimate obtained in the
present study (1.1 cases/million doses) and a reporting rate obtained from VAERS data (1.67 cases/million doses)11 but is based on relatively few doses.
Most of the previous reports of anaphylaxis after
diphtheria and tetanus vaccines are case reports.12–14
These reports support a causal relationship with anaphylaxis but do not quantify the risk. There were 16
reports of anaphylaxis or collapse after DT or DTP
vaccines over a 7-year period in the Northwest
Thames Region of the United Kingdom, but the
symptoms and severity of these reactions varied.15
All people with anaphylaxis or collapse recovered.
Approximately 268 200 children in this population
had completed courses of DTP or DT.
Although we observed no cases of anaphylaxis
after varicella vaccination, others have reported it. In
the United States, from March 1995 to July 1998,
VAERS received 30 reports consistent with anaphylaxis after varicella vaccine, for a reporting rate of 3
cases/million doses distributed.16 All patients with
anaphylaxis survived. Because the varicella vaccine
was licensed in the United States in 1995 and we
identified cases diagnosed through the end of 1997,
our population of children had received only 254 196
doses of varicella vaccine. At all 4 sites taken together, the upper limit of the CI for the risk of anaphylaxis after varicella vaccine was 14.5 cases/million doses. We hope to repeat these analyses in the
future as the VSD project collects more data on cases
of anaphylaxis prospectively.
We do not know which vaccine components might
have caused the episodes of anaphylaxis described in
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819
this study. Vaccine components that may cause allergic reactions include the vaccine antigen (eg, tetanus toxoid14), animal protein (eg, gelatin8), and antibiotics (eg, neomycin17). A report of anaphylaxis
after hepatitis B vaccination suggests that latex used
in vial stoppers and syringe plungers may also be a
cause of vaccine-associated anaphylaxis.18 A history
of anaphylaxis to a vaccine component is a contraindication to receipt of that vaccine.19 Furthermore,
children who have had an anaphylactic reaction to a
specific vaccine should not receive subsequent doses
of that vaccine, although desensitization may be possible in some cases (eg, among people with tetanus
toxoid allergy20,21).
CONCLUSIONS
Providers and patients can be reassured that the
frequency of vaccine-associated anaphylaxis is very
low. Nevertheless, providers should be prepared to
provide immediate treatment should it occur.
ACKNOWLEDGMENTS
This study was supported by contract 200-0957 (the Vaccine
Safety Datalink project) with the Centers for Disease Control and
Prevention and the American Association of Health Plans.
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NEW DOCTORS SHY AWAY FROM PRIMARY CARE AGAIN
“The number of family practice positions filled by US medical school seniors fell
from 47%, while internal medicine matches slipped from 59% to 55%. Many of the
remaining positions will be filled outside the match by international medical
graduates and doctors of osteopathic medicine. . . The only primary care specialty
with much drawing power this year was pediatrics; more than two-thirds of its
slots were filled by US seniors.”
Medical Economics. May 9, 2003
Noted by JFL, MD
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RISK OF ANAPHYLAXIS AFTER VACCINATION